Monitoring options limited

Unfortunately, notes Caplan, little can be done to monitor veterans with RA for the development of cardiovascular risk factors. “Traditional risk scores like the ‘Framingham’ do not appear to work well with RA, so it’s probably not valid to use those kinds of traditional methods for assessing a patient’s risk,” he says.

European physicians, he notes, have recommended that providers increase the Framingham score by 50% when patients have RA, conceding that approach has not been adequately studied. “There is some common sense appeal to that approach, but I suspect there are other factors not included in the Framingham score that are also important – like depression, for example — so just doubling the score is too simple,” he says. In addition, notes Caplan, other biomarkers might be important in a person’s cardiovascular risk, and preliminary data in related inflammatory conditions show that the traditional factors do not completely explain increased risk.

“In the meantime, however, it’s all we have,” says Caplan. “At this stage, we have to rely on clinical judgment – particularly for men and in veterans, who appear to be at increased risk above and beyond even the risk of RA.” 

Aggressive treatment recommended

The good news is that, once a veteran is diagnosed with RA, changes can and should be made to their care. “I want to indicate that patients who have inflammatory diseases are also at risk for diabetes, hypertension, hyperlipidemia and depression – all cardiovascular risks,” says Banerjee.

Accordingly, he suggests some “common sense and well-known preventive measures.” These include blood-pressure control for these patients at “very precise and controlled levels” over a long period of time, and cholesterol goals maintained at or below recommended levels.

While not yet in the guidelines, he continues, most patients with RA also should be treated like those with coronary artery disease. “Treat them early on with aspirin, and also with angiotensin receptor blocking agents — unless contraindicated — for hypertension, and statin therapy for hyperlipidemia,” Banerjee recommends. He notes there also is a growing body of literature indicating that patients with a heightened inflammatory state that are treated with TNF Alpha antagonists (i.e., Enbrel, Humera) to curtail or shorten or abbreviate the inflammatory process may also see a positive effect in terms of reduced risk of cardiovascular disease. He adds, however, that this hypothesis is being tested in multiple small studies, “But a randomized trial needs to be done before a definitive conclusion can be made.”

“I personally would target an LDL below 100 — similar to a patient with diabetes; I would treat them as if they are diabetic, because that connotes the level of risk,” adds Caplan. “The second thing is that, given the relationship of smoking to the development of of RA, and also the severity and its relationship to cardiovascular disease, I counsel the patient on how crucial it is to stop smoking above and beyond their original risk.”

Reimold agrees and adds a word of caution: “These people present very late or as they get into serious trouble from the disease; even specialists must think about the increased incidence of cardiovascular events as in our literature it becomes clear there is also an increased risk of silent MIs — not as much of overt chest pain or overt symptoms like angina as a warning,” he says.

Accordingly, says Reimold, people who treat veterans with RA need to cast an even wider net and think about becoming much more aggressive in lowering cholesterol – “Even though this is not usually the field of the rheumatologist.” While this may be difficult to incorporate into a busy practice, he emphasizes, “It’s very important in the overall health of the rheumatoid patient.”

Banerjee adds that this should not just be the concern of specialists. “Primary-care doctors see these patients early on in the progress of the disease, and involving rheumatologists and cardiologists early on as well can have long-term implications of life and death,” he asserts.

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